A nurse is caring for a client who gave birth 2 hr ago.
The nurse notes that the client's blood pressure is 60/50 mm Hg. Which of the following actions should the nurse take first?.
Evaluate the firmness of the uterus (fundus).
Obtain a type and crossmatch.
Administer oxytocin infusion.
Initiate oxygen therapy by nonrebreather mask.
The Correct Answer is A
The correct answer is choice A.
Choice A rationale:
Evaluating the firmness of the uterus (fundus) is the first action the nurse should take when a client’s blood pressure drops postpartum. A soft or “boggy” uterus can indicate uterine atony, a leading cause of postpartum hemorrhage, which can lead to hypotension.
Choice B rationale:
Obtaining a type and crossmatch is important if the client needs a blood transfusion, but it is not the first action the nurse should take.
Choice C rationale:
Administering oxytocin infusion can help contract the uterus and control bleeding, but the nurse should first assess the uterus.
Choice D rationale:
Initiating oxygen therapy can help if the client is hypoxic, but the nurse should first assess the uterus.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is choice B.
Choice A rationale:
The term “-1” in a vaginal examination does not refer to the effacement of the cervix. Effacement is usually expressed as a percentage.
Choice B rationale:
In a vaginal examination, “-1” refers to the station of the fetus. A “-1” station means that the presenting part of the fetus (usually the head) is 1 cm above the ischial spines.
Choice C rationale:
The term “-1” in a vaginal examination does not refer to the dilation of the cervix. Dilation is usually measured in centimeters, from 0 (no dilation) to 10 (fully dilated).
Choice D rationale:
A “-1” station does not mean that the presenting part is below the ischial spines. It means that it is above the ischial spines.
Correct Answer is C
Explanation
The correct answer is choice C.
Choice A rationale:
A 1-minute Apgar score of 5 points does not necessarily indicate a congenital heart defect or an immature respiratory system.
Choice B rationale:
An Apgar score of 5 points at 1 minute does not require immediate and aggressive interventions for survival.
Choice C rationale:
A 1-minute Apgar score of 5 points indicates that the infant is experiencing moderate difficulty in adjusting to extrauterine life.
Choice D rationale:
An Apgar score of 5 points at 1 minute does not indicate that the infant is adjusting well to extrauterine life.
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